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`r- SAN JUAQUIN LU_LAL-Ht,AL I,H—U1S I KiL l <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No.,7 <br /> Telephone: (209) 465-6:7.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Complete .In Triplicate <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or' install the work herein described. This application is made in compliance with San <br /> Joaquin County. Ordinance No.- -1862 and the Rules and Regulations of the San Joaquin Local Health <br /> Dstrict. <br /> EXACT STREET ADDRESS (� J��7 �K} CITY/TOWN',65 A✓ <br /> Owner's Name .� ��� h - _ Phone /9 <br /> Address r4 moi-, -e- C i ty�� <br /> Contractor' s Name ate. - - �✓ t Li censeQ22DlD PhoneW "aQ:Z <br /> a <br /> ',S CERTIFICATE OF WORKMAN'S CIPENSATIO'N INSURAINCE-ON .FILE WITH SJLHD? YES 440 <br /> TYPE OF WORK (Check) :--NEW-WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTiON-❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER 0 <br /> PUMP INSTALLATION ❑ PUMP, REPAIR❑ PUMP REPLACEMENT A..- <br /> DISTANCE TO NEAREST: "SEPTIC TANK SEWER LINES PIT PRIVY 'S v <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER „Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL "1 <br /> INTENDED USE• TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of .01-1- Excavation <br /> Domestic/private Drilled Dia..,,pf,, Wel,l Casing , <br /> Domestic/public Driven Gauge*of Casing_ , <br /> Irrigation Gravel Pack Depth of Grout Seal ` r <br /> Cathodic Protection Rotary . Type of Grout <br /> Disposal Other Other Information <br /> Geophysical -. Surface Seal Installed by <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: State Work Done QdX16C� <br /> •e� u-e 7 .2 IL .s TSL Scz <br /> PUMP REPAIR:_ _ ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Materia and Procedure <br /> I hereby certify that I have prepared this application and'-thatathe'work will be done in accordant <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent' s signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman' s Compensation <br /> laws of California. " <br /> I WILL CALL OR A GROUT NSPEC ION PRIOR TO GROUTING AND A FIN INSPECTION. <br /> { SIGNED TITLE: ! DATE:Z�� <br /> (DRAW PLOT L N ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 01 r"+ <br /> APPLICATION ACCERT.ED BY, — DATE 7Z <br /> 1 ADDITIONAL COMMENTS-' <br /> ' <br /> PHASE II -GROUT INSPECTION , / PHASE _Jj I INAL JINSPECTIONZ <br /> INSPECTION BY DATE N INSPECTION" S �.�' DATE <br /> r <br /> EH 1426 PP,►-_. 12-77 _ 1 /78 2M <br />